TY  - JOUR
TI  - Coaching patients On Achieving Cardiovascular Health (COACH): a multicenter randomized trial in patients with coronary heart disease
AU  - Vale, M.
AU  - Jelinek, M.V.
AU  - Best, J.D.
AU  - Dart, A.
AU  - Grigg, L.
AU  - Hare, D.
AU  - Ho, B.
AU  - Newman, R.W.
AU  - McNeil, J.J.
AB  - Background  Disease management programs in which drugs are prescribed by dietitians or nurses have been shown to improve the coronary risk factor profile in patients with coronary heart disease. However, those disease management programs in which drugs are not prescribed by allied health professionals have not improved coronary risk factor status. The objective of the Coaching patients On Achieving Cardiovascular Health (COACH) study was to determine whether dietitians or nurses who did not prescribe medications could coach patients with coronary heart disease to work with their physicians to achieve the target levels for their total cholesterol (TC) and other risk factors.  Methods  Multicenter randomized controlled trial in which 792 patients from 6 university teaching hospitals underwent a stratified randomization by cardiac diagnosis within each hospital: 398 were assigned to usual care plus The COACH Program and 394 to usual care alone. Patients in The COACH Program group received regular personal coaching via telephone and mailings to achieve the target levels for their particular coronary risk factors. There was one coach per hospital. The primary outcome was the change in TC (ΔTC) from baseline (in hospital) to 6 months after randomization. Secondary outcomes included measurement of a wide range of physical, nutritional, and psychological factors. The analysis was performed by intention to treat.  Results  The COACH Program achieved a significantly greater ΔTC than usual care alone: the mean ΔTC was 21 mg/dL (0.54 mmol/L) (95% confidence interval [CI], 16-25 mg/dL [0.42-0.65 mmol/L]) in The COACH Program vs 7 mg/dL (0.18 mmol/L) (95% CI, 3-11 mg/dL [0.07-0.29 mmol/L]) in the usual care group (P<.0001). Thus, the reduction in TC from baseline to 6 months after randomization was 14 mg/dL (0.36 mmol/L) (95% CI, 8-20 mg/dL [0.20-0.52 mmol/L]) greater in The COACH Program group than in the usual care group. Coaching produced substantial improvements in most of the other coronary risk factors and in patient quality of life.  Conclusions  Coaching, delivered as The COACH Program, is a highly effective strategy in reducing TC and many other coronary risk factors in patients with coronary heart disease. Coaching has potential effectiveness in the whole area of chronic disease management.  CLINICAL TRIALS have shown that the reduction of total cholesterol (TC) and low-density lipoprotein cholesterol (LDL-C),1- 3 the treatment of hypertension,4 and the performance of regular exercise5 have reduced mortality in patients with coronary heart disease (CHD). However, evidence from all over the world has shown that these advances are only being partially applied in clinical practice.6- 10 The concept has arisen of a treatment gap in CHD—the difference between evidence-based medicine and the real world.11  Strategies to address the treatment gap have been usually aimed at the physician, and these have often been ineffective.12,13 Strategies that target the patient have become known as disease management programs.14 A systematic review performed by McAlister et al14 concluded that these programs are effective in improving coronary risk factors. However, closer inspection of these disease management programs reveals that there are 2 distinct types of programs, which, until now, have been inappropriately grouped together: (1) those in which dietitians or nurses prescribe medication (usually lipid-lowering agents) directly to patients and (2) those in which dietitians or nurses do not have prescribing rights. Published work shows that all of the effective programs involved the prescription of medication(s) directly to patients.15- 18 Not surprisingly, the effectiveness of these interventions was attributable to progressive titration of lipid-lowering drug therapy with monitoring of the risk factor level until the target was achieved. On the other hand, none of the programs in which drugs were not prescribed by allied health professionals was effective in improving the coronary risk factor profile in patients with CHD, despite improving health behaviors.19- 24  Although programs that involve the direct prescription of medication to patients are clearly effective, they may be seen as competitive with usual medical care in some environments and may thus be counterproductive by alienating the usual treating physician. There is a role for a program that can achieve risk factor reduction in patients with CHD without involving support staff directly in the prescribing of drugs to patients. This has been the rationale for our development of the Coaching patients On Achieving Cardiovascular Health (COACH) Program to bridge the treatment gap in patients with CHD.  The COACH Program intervention was not founded on the application of theoretical principles. It is an empirical technique based on the head coach's experience as a secondary school teacher. The COACH Program is a training program for patients with CHD in which a health professional coach trains patients to aggressively pursue the target levels for their particular coronary risk factors while working in partnership with their own physician(s). The coach is hospital based and uses the telephone and mailings to provide regular coaching sessions to patients after discharge from the hospital. Coaching is directed at the patient and not at the treating physician. Patients are coached to know their risk factor levels, the target level for their risk factors, and how to achieve the target levels for their risk factors. Patients are persuaded to see their physician and ask for appropriate prescription of medication(s). Coaching also trains patients to follow appropriate lifestyle measures. Coaching aims to enable patients to drive the process of achieving and maintaining the target levels for their risk factors.  In a pilot study, we showed that one coach at a single institution reduced serum TC levels by 21 mg/dL (0.54 mmol/L) compared with usual medical care by using this simple approach.25 The beneficial effect of the coaching seemed to be due to the patient's better adherence to the nutritional advice given by the coach and to the patient's better adherence of the treatment prescribed by the usual medical practitioner.25 The current study was designed to test whether The COACH Program could achieve similar results in a much larger sample of patients spread over 6 university teaching hospitals, with a different coach in each hospital. In addition, we also determined the impact of coaching on a wide range of other modifiable coronary risk factors.
IS  - 22
JO  - Archives of Internal Medicine
PY  - 2003
SP  - 2775
UR  - archinte.jamanetwork.com/article.aspx?articleid=757469&resultclick=1%C2%A0#References
VL  - 163
LA  - English
ER  -